What does this service provide?

Who we are

We are an award-winning specialist homeless health inclusion team.

The team consists of nurses, health care assistants, a nurse prescriber, an occupational therapist, an associate therapist, and a physiotherapist.

We have a full-time homeless in-reach nurse at the hospital as part of a wider multi-agency team, including colleagues from ARCH Healthcare, Justlife and Housing.

What we do

We work in a trauma informed way with patients with tri-morbidity, (3 or more chronic health conditions). Our goal is to help patients who struggle to engage with primary and secondary healthcare to manage their health needs.

Many of our patients really struggle to engage with services, and will often disengage with healthcare and social services. This lack of trust is often caused from previous difficult experiences with healthcare professionals and other agencies.

Homeless and vulnerably housed people are a marginalised group. Many have multiple compound needs, addiction issues, and are very disadvantaged. They often feel judged by the health and adult social care system, and struggle to access standard NHS services without support, from the multi agencies involved in this citywide issue.

We outreach to people living in emergency, temporary and supported accommodation, those who are of no fixed abode, and those who are sofa surfing. This group often have problems with physical, psychological, and mental health issues and substance misuse. Our patients often have social care needs and are deteriorating with early onset frailty and ageing.

As a team we provide outreach, home visits, and run clinics in the city providing multi-disciplinary care in the community.

We understand complex needs and help to create realistic solutions to help support patients to trust and engage in services. We work collaboratively with other agencies, and our partners. The hospital-based pathways team help our patients to feel reassured that they have a point of contact if they are admitted into hospital.

We work collaboratively with our third sector colleagues, St Mungo’s and Change Grow Live, who outreach and support people who are street homeless and vulnerably housed. This includes support and solutions around substance misuse and helps to rebuild lives.

We help advocate for patients who have challenging behaviours, and who can be judged and not fully understood. This may be because of an abusive and traumatic childhood, or violent adult experiences, trauma, and PTSD.

Many of our patients chose to use illegal substances and have entrenched addiction. The route is usually intravenous, subcutaneous, or smoked. The drugs commonly used are crack, cocaine and heroin.  The effects from illicit substance misuse, are used to block out and symptom manage the pain associated with past traumatic experiences.

We holistically assess the individuals care needs, working in a solution focused way to support harm-minimisation if they wish to continue to use illicit substances safely.

We collaborate with other services, working towards detox and rehabilitation to help them focus better on other aspects of their lives.

Our patient group has multiple compound needs and are multiple disadvantaged. We work as part of a wider multi-agency team that includes, GPs, housing, adult social care, mental health, substance misuse services and third sector colleagues to best support the needs of all our patients.

Appointment information

Appointment types

We offer both face-to-face visits and telephone appointments.

Where will my appointment be?

We run drop-in clinics, with no need for an appointment. If you need further support, we can visit you at home.

If you live in emergency, temporary or supported accommodation, the nurse, physiotherapist, and occupational therapist will make a one-to-one home visit or at a safe place of your choice.

If you are sleeping rough, there are nurse and physiotherapy drop-in clinics in day centres. We also reach out to people on the streets.

What can I expect at my appointment?

At your first appointment, one of our team will meet you, take time to hear about your health condition, make an initial assessment and then plan how to best support you.

What happens after my appointment?

Once you have received the support and care you need from our team, you will be discharged. If further support is needed, we will refer you on to the relevant services.

How we can support you

Occupational Therapists

Our Occupational Therapists can support your everyday needs, such as cooking, household tasks, new hobbies, and life skills. They also provide equipment to help with daily living and palliative care, provide coping strategies for relaxation and anxiety management and create comfortable spaces for you to meet and enjoy activities.


Our Physiotherapists can support you if you have fallen or have balance issues, musculoskeletal issues or pain, respiratory conditions, or post-orthopaedic surgery rehabilitation. This support could be in the form of advice, exercises, or equipment.


Our nurses can help with any medication queries or general medication management.

They can administer new injections and provide support for long term conditions such as diabetes, asthma, liver disease, continence (bowel and bladder assessment and support) and alcohol related dementia.

They can facilitate screening for sexual health, blood borne infectious diseases, for example: Hepatitis C and HIV and airborne viruses like Tuberculosis.

They can facilitate pregnancy testing and deal with complexities arising from domestic violence and survivor sex.

Our nurses can also provide support with wound and skin care and support deteriorating patients who are frail, and palliative, as well as supporting patients at the end of their life.

Hospital Liaison Nurses

Our hospital liaison nurses can support you in A&E and when you are admitted into hospital. They will support you during your admission and liaise with hospital staff to help plan your discharge.

Once you have been discharged, they can help you access the relevant support services and the Homeless Intermediate Care Service.

Our team can also provide medium to long-term co-ordination of care and support for those who need palliative care, end of life care or continuing health care. We can also support those struggling with frailty, safeguarding and their mental capacity.

How can I access this service?

To access our service, can be referred by a health care professional, who will need to complete our referral form. This will need to be emailed to the address mentioned on the form.

Alongside the referral form we have a team landline and mobile number. These can be found in our contact details at the bottom of this page.

You can self-refer at one of our drop-in clinics at Off the Fence or First Base Day Centre, or ask a member of the team there to refer for you. See the bottom of the page for clinic details.

We take referrals from high/medium support hostels in the city (also known as supported accommodations) and can take direct referrals from keyworkers and patients through our clinics and online using the referral form.

We are not commissioned for low support accommodation but will support patients on a transitional care plan who are moving on from higher support and refer on to the community nursing team (integrated primary care) if appropriate, for continuing care.

Any frontline staff working in the community can make a referral into the team for people who are rough sleeping, in emergency or temporary accommodations, or sofa surfing, who they are concerned about.   

How can I contact this service?

Contact details
Telephone: 01273 696 011 extension 1930/1931 or 07341 049 449
Opening hours

We are open Monday to Friday, from 8:00am to 4:00pm. We are closed on weekends and bank holidays.

Waiting times

Our team aim to contact you within four weeks.

Off The Fence Clinic

Off the Fence clinic is every second Monday, from 1:00pm to 3:00pm.

Address: 37 Portland Road,

You can find us using the what3words address snippet below on the what3words website:

Alternatively, use the Google map below to get directions and plan your journey:

First Base Day Centre Clinic

First Base Day Centre is every Wednesday, from 10:00am to 12:00pm.

Address: First Base Day Centre
St Stephen’s Hall, Montpelier Place,
Brighton, BN1 3BF

You can find us using the what3words address snippet below on the what3words website:

Alternatively, use the Google map below to get directions and plan your journey:

William Collier House Clinic

William Collier House clinic is held on a Thursday, 12:00pm to 2:00pm

Address: 40 North Road

You can find us using the what3words address snippet below on the what3words website:

Alternatively, use the Google map below to get directions and plan your journey:

Glenwood Lodge Hostel Clinic

Glenwood Lodge Hostel clinic is held on a Friday, 12:00pm to 2:00pm.

Address: 36-37, Grand Parade, Brighton and Hove, Brighton BN2 2QA

You can find us using the what3words address snippet below on the what3words website:

Alternatively, use the Google map below to get directions and plan your journey:

Let's get social

You can also get involved by engaging with our service's social media accounts by helping with the latest fundraisers and events.

Get the best from your NHS

If you want to share a compliment, raise a concern or if you are just not sure who to speak to you can contact our Patient Advice and Liaison Service (PALS).